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1994, 05-05 Permit App: 94003969 Sewer TL9 11 Y SEWER CONNECTION PERMIT APPLICATION FORM *THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY AND SIGNED OR PERMIT WILL NOT BE ISSUED. c I` �1 � (IF KNOWN) (14 .. (3C11/3JOB ADDRESS : 5-6(251 v/ F-�QPARCEL NUMBER: CITY: `� C)/19/1`4- STATE: 1/(24 , ZIP CODE: / OWNER NAME: /6©�9G A) Pe-ALS-t) /J ADDRESS : J) CITY$PO/(4 /UF STATE: /11/74 . ZIP CODE: PHONE NUMBER: ,4-) :35- 2(.5S-7 PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? YES (CIRCLE ONE) *IF PROPERTY OWNER INSTALLING SEWER THEY MUST FIRST CONTACT THE UTILITIES DEPARTMENT FOR CONSTRUCTION REQUIREMENTS BEFORE PERMIT IS ISSUED. CONTRACTOR: 1-1-G Cp R -+1 tai* (r)f ADDRESS : 1,38 l b E • I2" AVe-, CITY: . ,-x n P, STATE: t.IA ZIP CODE: q 9 21 PHONE NUMBER: 92.11 1 - STATE CONTRACTORS LICENSE NUMBER: --(L..-C.- C- 0 -7\4- 4---- .1-01M (� UTILITIES INSTALLERS PERMIT NUMBER: INTERIOR PLUMBING ALTERATIONS? 41/11m NO (CIRCLE ONE) INTERIOR ALTERATION BY: /3/ ___C -71-4.119-7 ADDRESS : PHONE NUMBER: CITY: STATE: ZIP CODE: *ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC. THAT WILL BE CONNECTED TO THE SEWER. SEWER CONNECTION • # OF BUILDINGS / X 50. 00 = .SD, D d INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS ( X 35. 00 = -‘O TOTAL PERMIT FEE DUE $ '$O C) APPLICANT SIGNATURE• ��-- DATE: 174-.- 8?:- /. ^.- 8 - /. SPOKANE COUNTY DEPARTMENT OF BUILDINGS WEST 1026 BROADWAY AVENUE, SPOKANE, WA. 99260 (509) 456-3675